Ureteroarterial fistula: a case report

Early diagnosis and management of arterio-ureteral fistulas: A literature review

OBJECTIVES

Arterio-ureteralfistula (AUF) is an infrequent but potentially life-threatening condition. The aim of this study was reviewing the literature to build a flow-chart useful for an early and effective diagnosis and treatment of this pathology.

MATERIALS AND METHODS

A literature search in PubMed was conducted. In addition, retrieved articles were cross-referenced. Data parameters included oncologic, vascular and urological history, diagnostics, treatment, and follow up were collected using a standard template by 2 independent reviewers.

RESULTS

A total of 140 cases of AUF out of 172 available in the literature at the time of the review, were considered. All patients presented gross hematuria. Chronic indwelling ureteral catheter (CIUC); history of pelvic surgery (HPS) and history of pelvic radiotherapy (HRT) were present respectively in 81%, 62.1%and 58.6% of the sample. The most predominant location of AUF was at the common iliac artery ureteral crossing. Angiography with provocative measures had the highest diagnostic sensitivity (50%) and endovascular treatment with stent-graft placement across the fistula is the current state of the art treatment choice.

CONCLUSIONS

Failure to diagnose can postpone a potentially life-saving targeted therapy and lead to complications. The identifi-cation of the Trifecta hematuria, history of pelvic surgery (HPS) and history of pelvic radiotherapy (HPR) would allow the identity-fication of patients at high risk of AUF, who may benefit from more sensitive early diagnostic investigations such as CT angiography and provocative angiography. The treatment of choice in case of AUF to date consist in endovascular prosthesis placement.

Uretero-arterial fistula: Six new cases and systematic review of the literature

AIM

Secondary uretero-arterial fistulas (SUAF) are uncommon, underrated and threatening for any patient. Gross hematuria is a clinical symptom of this pathology for patients with history of pelvic radiotherapy, complex pelvic surgery or long-term ureteral stenting. The purpose of this work is to assess risk factors, diagnosis and treatment of SUAF.

METHODS

Monocentric and retrospective series of 6 new cases illustrated by a literature review through MedLine and Pubmed using the keywords "arterio-ureteral fistula", "arterio iliac fistula" and "ilio-ureteral fistula". We excluded uretero-arterial fistula following vascular surgery.

RESULTS

Our series included 4 men and 2 women. All patients had a history of complex pelvic surgery and long-term ureteral stenting. Three patients had history of pelvic radiotherapy. They all had inaugural macroscopic haematuria episode. Two fistula cases were diagnosed on 5 repeated CT-scans. In 2 out of 5 cases, arteriography highlighted the fistula. Fistulas were generally located at the left common iliac artery. An endovascular stent was placed in 5 out of 6 cases. One patient needed open surgery. After treatment, 3 patients remained alive, 3 patients died either by a fistula relapse or by complications late in the treatment.

CONCLUSION

SUAF are uncommon, but serious. Today, there is no specific recommendation regarding complex treatment of these fistulas. Endovascular stents seem to be a good therapeutic option.

LEVEL OF PROOF

3.

Uretero-Iliac artery fistula: a rare cause of haematuria

A woman in her mid-forties with a history of cervical cancer requiring chemoradiation presented with bilateral ureteral strictures secondary to radiation therapy. The ureteral obstruction was initially relieved with bilateral percutaneous nephrostomy tubes, and subsequently, bilateral ureteral stents. Over the course of 8 months, she presented with multiple episodes of severe gross haematuria. This persisted even after stent removal and conversion back to percutaneous nephrostomy tubes. The initial evaluation, done with concern for an uretero-iliac artery fistula, which included bilateral retrograde pyelograms and CT angiography was non-diagnostic. Given continued haematuria, repeat endoscopic evaluation was undertaken; on retrograde pyelogram, brisk contrast was seen to pass into the arterial system, consistent with a left ureteroarterial fistula. The patient underwent endovascular iliac artery stent placement. Subsequently, the patient underwent resection of the iliac artery with endovascular graft in situ, left distal ureterectomy with proximal ureteral ligation following femoral-to-femoral bypass. This allowed for complete resolution of the patient's gross haematuria episodes.

Iliac Artery-Uretero-Colonic Fistula Presenting as Gastrointestinal Hemorrhage and Hematuria: A Case Report

Background: The experience with uretero-arterial fistulas has been limited. However, the aggressive treatment of pelvic tumors with surgical resection and radiotherapy, along with liberal use of ureteral catheters, has been attributed to an increase in their incidence. Unless they are promptly diagnosed and treated, uretero-arterial fistulas are associated with considerably high rates of morbidity and mortality. Urologists need maintain a high degree of suspicion for uretero-arterial fistula in high-risk patients. We herein present the clinical course of an iliac artery-uretero-colonic fistula.

Case Presentation: A 67-year-old woman with a history of colon cancer who underwent laparoscopic high anterior resection in July 2010. A ureteral stent inserted to right ureteral stricture, which developed as a result of local recurrence of the tumor in September 2010. She had undergone chemoradiotherapy, but the lesion had slowly increased in size. During the replacement of the ureteral stent in April 2016, she immediately experienced bladder tamponade, bloody bowel discharge, and hypotension. Contrast CT revealed a complex fistula between the right distal ureter and the right internal iliac artery. Furthermore, contrast medium flowed into the intestinal tract through the tumor. The patient was therefore diagnosed with internal iliac artery-uretero-colonic fistula. Arteriography revealed a right uretero-internal iliac artery fistula, and the embolization of the right internal iliac artery was performed. The right ureteral stent was removed. Her hematuria and bloody bowel discharge disappeared, but right nephrostomy was performed because she presented with acute pyelonephritis to ureteral obstruction.

Conclusion: In the present case, the uretero-arterial fistula was caused by the long use of an indwelling stent, chemoradiotherapy, infection, and an increase in the size of the lesion. When a suspected uretero-arterial fistula is accompanied by bloody bowel discharge, we should consider the possibility of traffic to the intestinal tract.

Arterioureteral Fistula

Arterioureteral fistula is a rare clinical entity that has been reported more frequently over the past decade. The risk factors for arterioureteral fistula include previous pelvic or urologic surgery, ureteral stenting, pelvic irradiation, and previous vascular pathology. All patients who present with this clinical entity have at least one of these risk factors, and the majority of patients have more than one risk factor. Radiographic demonstration of an arterioureteral fistula may be difficult and often requires more than one diagnostic modality. Angiography and retrograde ureterography appear to be the most helpful in establishing a diagnosis. The literature suggests that patients with a diagnosis of arterioureteral fistula before surgery have an increased incidence of renal salvage and decreased mortality. Methods of repair have been varied, but in the past several years, endovascular approaches to this problem have become more common. The authors report two cases of arterioureteral fistulae, one managed operatively, and one managed by endovascular placement of a covered stent. The literature is reviewed, and etiology, diagnosis, surgical therapy, and endovascular therapy are discussed.

External iliac vein - transplant ureteral fistula combined with renal cell carcinoma: an unusual case of hematuria

Iliac vein-ureteral fistula is a rare cause of hematuria. The diagnosis of an iliac vein-ureteral fistula can be elusive even with the use of multiple methods. With regards to the treatment, there appears to be a shift in management from primarily open surgical to primarily angiographic management. We present a unique case of an external iliac vein – transplant ureteral fistula. A 48 year-old female complained of recurrent gross hematuria. She underwent transplant nephrectomy and radical left nephrectomy because of rejection of transplanted kidney and cystic renal cell carcinoma when the hematuria arose for the first time. Ten months later, the hematuria recurred again, and cystoscopy showed bleeding from the right transplant ureteral orifice. Open exploration confirmed the diagnosis of external iliac vein – transplant ureteral fistula. Diagnostic difficulties and treatment dilemma of such a rare cause of hematuria are also discussed.

Uretero-iliac artery aneurysm fistula: A rare but fatal cause of haematuria

Visible haematuria from an uretero-iliac artery aneurysm fistula (UIAF) offers a diagnostic challenge and early accurate diagnosis can have a significant impact on prognosis. We report a 90 year old gentleman who presented with visible haematuria and clot retention. He required catheterisation, bladder washout and a blood transfusion. Subsequent imaging revealed an abdominal aortic aneurysm and bilateral iliac artery aneurysms with left sided hydronephrosis and hydroureter. There was no radiological evidence of a fistula between the left ureter and iliac aneurysm. Due to associated co-morbidity surgical intervention was not deemed suitable. Although his haematuria initially settled he developed catastrophic haematuria and died. Post-mortem confirmed UIAF causing fatal haemorrhage. In this report we discuss the diagnostic challenges and management options for this condition.

Ureteroarterial fistula

Ureteral-iliac artery fistula (UIAF) is a rare life threatening cause of hematuria. The increasing frequency is attributed to increasing use of ureteral stents. A 68-year-old female presented with gross hematuria. She had prior low anterior resection for rectal cancer and a retained ureteral stent. CT abdomen and pelvis showed a large recurrent pelvic mass and a retained stent. The patient underwent cystoscopy which showed a normal bladder. Upon removal of the stent, brisk bleeding was noted coming from the ureteral orifice. Antegrade pyelogram was done which revealed a UIAF. Angiography was done and a covered stent was placed. Multiple treatment options are available. All must consider management of the arterial and ureteral side. The arterial side may be addressed by primary open repair, embolization with extra-anatomic vascular reconstruction, or endovascular stenting. The ureter can be managed with nephroureterectomy, ureteral reconstruction, placement of a nephrostomy tube, or ureteral stenting. Being minimally invasive, we believe that endovascular stenting should be the preferred therapeutic option as it also corrects the source of bleeding while preserving distal blood flow.

Primary uretero-iliac fistula: the unusual source of haematuria

Uretero-iliac fistula is a rare cause of frank haematuria. The aetiology of such fistula is commonly iatrogenic. We present a unique case of a primary aorto-iliac fistula in the absence of an aneurysm or arteriovenous malformation. The diagnosis was demonstrated by ureteroscopy and real-time retrograde ureterogram. Multiple arterial embolisation of the fistula had failed, and the patient underwent a successful ureterolysis and ligation of fistula. We demonstrate the diagnostic difficulties and treatment dilemma of such rare cause of haematuria.

Endovascular Treatment for an Iliac Artery–Ureteral Fistula with a Covered Stent

Iliac artery-ureteral fistula (IAUF) is a rare entity that has a potential risk of life-threatening hemorrhage. It is difficult to diagnose and treat appropriately. Conventional treatment for the disease consists of surgical ligation and vascular reconstruction or coil embolization. Surgical treatment is usually difficult for patients with several risk factors. In recent years, endovascular stent-graft treatment for iliac artery pseudoaneurysm has been reported. The present report describes two cases in which endovascular covered stent-graft treatment was successfully applied to treat IAUF, with good clinical outcomes.

Ureteroiliac artery fistula: Diagnosis and treatment algorithm

OBJECTIVES

To review the diagnosis and treatment of ureteroarterial fistulas and to develop a management algorithm. Long-term ureteral stenting, along with pelvic surgery and radiotherapy, have led to an increased incidence of ureteroarterial fistulas. Experience diagnosing and treating these fistulas has been limited to case reports.

METHODS

A retrospective chart review from 1975 to 2004 revealed eight ureteroarterial fistulas in 7 patients at our institution. The patient demographics, presenting symptoms, and diagnostic studies were reviewed. Also, we analyzed the treatment, hospital course, and long-term outcomes.

RESULTS

Ureteroarterial fistulas were more common in women (86%) than in men. All patients presented with gross hematuria, and 57% had lateralizing flank pain. Risk factors included chronic indwelling stents (87%), previous pelvic external beam radiotherapy (71%), pelvic surgery (100%), and vascular disease (87%). Provocative angiography was diagnostic in only 63% of cases. Although not sensitive, cystoscopy revealed lateralized, pulsatile hematuria in all cases when performed. Treatment ranged from endovascular stenting with nephrostomy tube to primary surgical repair with nephrectomy.

CONCLUSIONS

On the basis of this review, we propose a systematic diagnostic and treatment approach to a serious disease process. The use of these proposed algorithms will minimize unnecessary testing, increase the speed of diagnosis, and potentially improve overall outcomes of patients with ureteroarterial fistulas.

Ureteroarterial fistula with ruptured anastomotic pseudoaneurysm: successful management with vascular exclusion, extra-anatomic bypass and nephrectomy--a case report

Ureteroarterial fistula is a rare but life-threatening condition most often arising as a consequence of combined vascular and urologic pathology. Only about 70 cases are reported in the English literature. Principles of repair include complete vascular isolation, extra-anatomic bypass, and urinary stream diversion away from major vascular conduits. The case presented herein is only the second reported instance of fistulization to an anastomotic pseudoaneurysm of an iliopopliteal bypass.

Treatment of Ureteroarterial Fistulae with Covered Vascular Endoprostheses and Ureteral Occlusion

BACKGROUND

Ureteroarterial fistulae (UAFs) are a rare entity, often difficult to identify, and associated with a high mortality rate. This fact has been attributed to a delay in diagnosis and treatment. Five conditions that can predispose to the development of this uncommon entity have been described: prior pelvic surgery, prolonged ureteral stenting, radiation therapy, previous vascular surgery and vascular pathology.

METHODS

We present 4 patients with UAFs and at least three of the above-mentioned conditions. Ureteral ischemia and subsequent necrosis promote the formation of these fistulae. The constant pulsation of the iliac artery is transmitted to an already compromised ureter containing a stiff intraluminal foreign body, resulting in pressure necrosis, most likely where the ureter crosses the iliac artery.

RESULTS AND CONCLUSION

Cases were managed percutaneously with a combination of the deployment of a covered prosthesis and, when needed, with mechanical occlusion of the ureter. Hematuria stopped in all the patients with no evidence of immediate rebleeding. One patient presented a new episode of vaginal bleeding 13 months after endograft placement and ureteral embolization. Arteriography showed the presence of a hypogastric artery pseudoaneurysm that was occluded using coils. No new bleeding has occurred in this patient 12 months after the second embolization. At present all 4 patients are alive with follow-up periods of 5, 9, 11 and 25 months since the first procedure.

Endovascular approach to treating secondary arterioureteral fistula

Two patients with the rare entity of arterio-ureteral fistula are presented. Both highlight the predisposing factors of radiation, major surgery in the region, history of vascular surgery and presence of double-J-stent. Both patients presented with the clinical sign of intermittent gross hematuria. Both patients were successfully treated by endovascular intervention using graft covered stent.

Arterio-ureteral fistula--a systematic review

OBJECTIVE

To review published reports on arterio-ureteral fistula.

METHOD

Literature search.

RESULTS

Eighty cases were identified. Primary fistulas were mainly seen in combination with aortoiliac aneurysmal disease. Secondary fistulas were seen after pelvic cancer surgery, often with radiation, fibrosis and ureteral stenting or after vascular surgery with synthetic grafting. The dominating symptom is massive haematuria, often with circulatory impairment. The clue to a rapid and correct diagnosis is a high degree of suspicion. Most frequently diagnosis has been obtained through angiography or pyelography. When there is a ureteral stent manipulation it will often provoke bleeding and lead to diagnosis. The fistula must be excluded and a vascular reconstruction made. Most frequently this has been obtained through occlusion of the fistula and an extra-anatomic reconstruction (femoro-femoral crossover). Recently stent-grafting has been successfully used but follow-up is short.

CONCLUSION

Arterio-ureteral fistula is rare and should be suspected in patients with complicated pelvic surgery and massive haematuria, especially where rigid ureteral stents have been placed.

Fatal recurrent ureteroarterial fistulas after exenteration for cervical cancer

BACKGROUND

Ureteroarterial fistula (UAF) is a rare occurrence. It can be difficult to diagnose with a high mortality. We report a case of a recurrent UAF.

CASE

A 38-year-old women diagnosed with cervical cancer had undergone pelvic exenteration for severe radiation-induced necrosis with a vesicovaginal and rectovaginal fistula after primary radiation therapy. Hemorrhage into the urinary tract necessitated surgical intervention and vascular repair with a femoral-femoral bypass. Although these measures were effective, the patient died 6 months later following an acute hemorrhage into her conduit. Arteriogram revealed a second UAF.

CONCLUSION

When urinary tract bleeding occurs in patients previously diagnosed with a gynecologic malignancy and treated with radiation therapy and extensive surgery with urinary diversion, UAF should be considered in the differential diagnoses.

Diagnosis and management of ureteroiliac artery fistula: value of provocative arteriography followed by common iliac artery embolization and extraanatomic arterial bypass grafting

PURPOSE

We describe an effective multidisciplinary approach to the diagnosis and management of ureteroarterial fistulas that reduces morbidity and mortality.

MATERIALS AND METHODS

Five ureteroarterial fistulas in 4 patients were studied with standard and provocative arteriography (arteriography combined with ureteral manipulation). After establishing the diagnosis, each lesion was treated with percutaneous embolic occlusion of the common iliac artery followed by extraanatomic arterial bypass grafting. All patients had chronic ureteral stenting, prior pelvic irradiation, prior pelvic surgery and intrapelvic malignancy, and all fistulas presented with urinary tract hemorrhage.

RESULTS

Standard arteriography was nondiagnostic but provocative arteriography demonstrated the fistula in each case. Successful embolization of the common iliac artery followed by extraanatomic arterial bypass grafting precluded the need for laparotomy and preserved ipsilateral renal function.

CONCLUSIONS

Provocative arteriography followed by arteriographic common iliac artery embolization and extraanatomic bypass grafting was successful for the diagnosis and treatment of ureteroarterial fistulas. There was no mortality, limb loss or renal loss.

Autologous vein-covered stent for the endovascular management of an iliac artery-ureteral fistula: case report and review of the literature

Iliac artery-ureteral fistula is a rare entity that is being reported with increasing frequency. Patients with iliac artery-ureteral fistulas can be divided into two distinct groups on the basis of the factors that predispose them to having these fistulas. In group I the fistula is associated with degenerative iliac artery disease or previous arterial reconstructive surgery. Patients in group II have undergone some combination of the following procedures: pelvic extirpative surgery for malignancy, urinary diversion, radiation therapy, and ureteral stenting. The diagnosis of an iliac artery-ureteral fistula can be elusive even with the use of multiple imaging methods. Direct operative repair is technically demanding and is associated with high mortality rates. In recent years, treatment has shifted toward percutaneous embolization of the iliac artery and extraanatomic lower extremity vascular reconstruction for group II patients. In this report, the 24 group II patients with iliac artery-ureteral fistulas who previously have been described are reviewed, and a new endovascular treatment for this entity that uses a stented vein graft is detailed.

Ureteroarterial fistula: case report and review of the literature

Ureteroarterial fistulae are rare. We report 2 cases of this clinical problem. Ureteroarterial fistulae can occur in association with prolonged ureteral stenting, radiation therapy, vascular pathology, and prior pelvic or vascular surgery. Identification of a fistula is often difficult and requires the physician to be highly alert and vigilant. Diagnostic and therapeutic options for a ureteroarterial fistula are discussed.